Treatment of Children w Sexual Bhvr Probs audio

The Treatment of Children with Sexual Behavior Problems : 

The Treatment of Children with Sexual Behavior Problems Shelley Schuurman, PhD, LMSW Grand Valley State University School of Social Work Assistant Professor

Introductions : 

Introductions Shelley Schuurman, PhD, LMSW Grand Valley State University, School of Social Work Assistant Professor, 8th year of teaching Previous Work: Residential, Out Patient, Group home, Psychiatric Hospital Primary population: Abused and neglected children & adolescents and their families Primary Sources: Report of the Association for the Treatment of Sexual Abusers (ATSA) Task Force on Children with Sexual Behavior Problems (2008) William Friedrich Eliana Gil Beverly James Toni Cavanagh Johnson Who is in the audience?

Children with Sexual Behavior Problems: Definition : 

Children with Sexual Behavior Problems: Definition What is considered to be a Sexual Behavior Problem in Children? Children ages 12 and younger who initiate behaviors involving sexual body parts (ex. genitals, anus, buttocks, or breasts) that are developmentally inappropriate or potentially harmful to themselves or others.

Children with Sexual Behavior Problems: Definition : 

Children with Sexual Behavior Problems: Definition Although the term sexual is used, the intentions and motivations for these behaviors may or may not be related to sexual gratification or sexual stimulation. The behaviors may be related to curiosity, anxiety, imitation, attention seeking, self-calming, or other reasons. (Silovsky & Bonner, 2003).

Natural and Healthy Sexual Behaviors in Children : 

Natural and Healthy Sexual Behaviors in Children It is expected that 40-80% of children will engage in at least some sexual behaviors before thirteen years of age. Natural and healthy sexual exploration during childhood is: an information gathering process where children explore each other’s bodies by looking and touching (e.g. playing doctor) as well as explore gender roles and behaviors (e.g. playing house).

Natural and Healthy Sexual Behaviors in Children : 

Natural and Healthy Sexual Behaviors in Children Children involved in natural and healthy sexual play are of similar: Age Size Development Status and participate on a voluntary basis.

Natural and Healthy Sexual Behaviors in Children : 

Natural and Healthy Sexual Behaviors in Children Most of this sexual play is between children who have an ongoing mutually enjoyable play and/or school friendship The sexual behaviors are limited in type and frequency and occur in several periods of the child’s life. The child’s interest in sex and sexuality is balanced by curiosity about other aspects of his or her life.

Natural and Healthy Sexual Behaviors in Children : 

Natural and Healthy Sexual Behaviors in Children Natural and healthy sexual exploration may result in embarrassment but does not usually leave children with deep feelings of anger shame or anxiety. If the children are discovered in sexual exploration and instructed to stop, the behavior generally diminishes, at least in the view of adults. The feelings of the children regarding the sexual behavior is generally light hearted and spontaneous.

Characteristics of Problematic Sexual Behaviors in Children : 

Characteristics of Problematic Sexual Behaviors in Children The children engaged in the sexual behaviors do not have an ongoing mutual play relationship. Sexual behaviors which are engaged in by children of different ages or developmental levels. Sexual behaviors that are out of balance with other aspects of the child’s life and interest. Children who seem to have too much knowledge about sexuality and behave in ways more consistent with adult sexual expression. Sexual behaviors which are significantly different than those of other same-age children.

Characteristics of Problematic Sexual Behaviors in Children : 

Characteristics of Problematic Sexual Behaviors in Children Sexual behaviors that continue in spite of consistent and clear requests to stop. Children who appear unable to stop themselves from engaging in sexual activities. Children’s sexual behaviors which are eliciting complaints from other children and/or adversely affecting other children. Children’s sexual behaviors which are directed at adults who feel uncomfortable receiving them.

Characteristics of Problematic Sexual Behaviors in Children : 

Characteristics of Problematic Sexual Behaviors in Children Sexual behaviors which progress in frequency, intensity or intrusiveness over time. When verbal and/or physical expressions of anger precede, follow or accompany the sexual behavior. Children who use distorted logic to justify their sexual actions. (“She didn’t say no.”) When coercion, force, bribery, manipulation or threats are associated with sexual behaviors.

Factors to consider when determining whether sexual behavior is appropriate : 

Factors to consider when determining whether sexual behavior is appropriate SEXUAL PLAY: Is exploratory and spontaneous Occurs intermittently and by mutual agreement Occurs with children of similar age, size or developmental level, such as siblings, cousins or peers Is not associated with high levels of fear, anger or anxiety Decreases when told by caregivers to stop and Can be controlled by increased supervision

Factors to consider when determining whether sexual behavior is appropriate : 

PROBLEMATIC SEXUAL BEHAVIOR: is a frequent, repeated behavior, such as compulsive masturbation occurs between children who do not know each other well occurs with high frequency and interferes with normal childhood activities is between children of different ages, size and development level is aggressive, forced or coerced does not decrease after the child is told to stop the behavior causes harm to the child or others Factors to consider when determining whether sexual behavior is appropriate

Origins of Sexual Behavior Problems in Children : 

Origins of Sexual Behavior Problems in Children Origins of SBP are not clearly understood Early theories emphasized sexual abuse as the sole cause. Children who have been sexually abused do engage in a higher frequency of sexual behaviors than children who have not been sexually abused. Sexual abuse histories have been found in high percentages of children with SBP. This however, does NOT imply that ALL children who have been sexually abused will engage in SBP. Many children with SBP have no known history of sexual abuse.

Specific Risk Factors related to Children with a Sexual Abuse History : 

Specific Risk Factors related to Children with a Sexual Abuse History Research by Friedrich shows that children who have a sexual abuse history AND have some components of each of these five variables are more likely to have SBP. Let’s look at Friedrich’s Findings (Pink Sheet) Five Variables: Sexual Abuse Experience of the Child Child Child’s History Parent-Child Relationship Caregiver Characteristics

factors that Contribute to Sexual Behavior Problems in Children : 

factors that Contribute to Sexual Behavior Problems in Children Maltreatment Have been physically abused and/or neglected and emotionally abused. Have been sexually abused by direct physical contact to their bodies or being used to sexually stimulate others’ bodies Have been observed or photographed naked for the sexual stimulation of others. Substandard Parenting Practices Poor parental supervision Have been used to meet the emotion needs of a parents, which may be sexualized Have no model for appropriate intimacy

factors that Contribute to Sexual Behavior Problems in Children : 

factors that Contribute to Sexual Behavior Problems in Children Exposure to Domestic Violence Have observed physical violence to others, particularly parents/caregivers and/or siblings in their own home. Living in a Highly Sexualized Environment Live in places where sex is routinely paired with aggression, such as fights about sex, violent sexual language or forced sex. Live with parents who act in sexual ways after drinking or taking drugs regardless of the presence of children. Live in sexually explicit environment in which sex is used in exchange for drugs or to keep from being hurt. Exposure to Sexually Explicit Media Are confused based on what they see on television, video games, magazines, movies, or from “surfing the net.”

Typology and Subtypes : 

Typology and Subtypes Diverse Group Substantial number of young girls as well as boys No figures on incidence or prevalence Is still infrequent compared to adolescents or adults Subtypes Attempts have been made to construct subtypes Research isn’t bearing that out Instead, it’s really just a range of severity and intensity Children with more intense SBP tend to have comorbid mental health, social and family problems.

Break time ~ Be back at 10:30am : 

Break time ~ Be back at 10:30am

Assessment: Purpose : 

Assessment: Purpose What they are NOT Clinical assessments should not be confused with official investigations into whether or not an alleged behavior has occurred Purpose of a Clinical Assessment Individual assessment on a case-by-case basis should play a foundational role in intervention and treatment planning, as well as all decision-making for all children with SBP. (ATSA Report)

Assessment: Scope : 

Assessment: Scope Family Environment & Social Ecology Quality of the caregiver-child relationship, including positive engagement with child Adult caregiver capacity to monitor and supervise behavior Caregiver warmth and support shown to child, including attachment Presence of positive or negative role models in child’s social environment Types of discipline, limit setting, structure, or consequences applied and child’s response to it Emotional, physical and sexual boundary violations in the home

Assessment: Scope : 

Assessment: Scope Availability for opportunities for inappropriate behavior Extent and degree of sexual and/or violent stimulation in the child’s past and current environment Exposure to and protection from potentially traumatic situations Cultural factors of the home and community Factors related to resilience, or strengths and resources that can be developed

Assessment: Scope : 

Assessment: Scope Psychological and Behavioral Status Broad assessment of General Functioning is important because of the frequency of nonsexual behavior problems in this population Externalizing Behavior Problems Oppositional or Aggressive behavior Internalizing Behavior Problems Depression or Anxiety Post Traumatic Stress Disorder (prior sexual abuse) Developmental and Learning Problems

Assessment: Scope : 

Assessment: Scope Assessing Sexual Behavior and Contributing Factors Clear behavioral description of the sexual behaviors, including: when they began how frequently they occur how and whether they have changed or progressed over time Sequence the sexual behavior chronologically and correlate it with key events in the child’s life Multiple information sources are important to capture the complete picture (child, parents, other caregivers, other children, teachers)

Assessment: Scope : 

Assessment: Scope Determine the extent to which the sexual behavior is: Self-focused Other directed Planned Aggressive Coercive Determine the prior efforts or lack of efforts made by parents or caregivers to correct the behavior and the child’s response to these efforts Identify situations or circumstances in which the SBP seems to occur

Assessment: Scope : 

Assessment: Scope Individuals presume that an assessment must find a specific event that caused the SBP or Presume that finding the root cause is needed to solve the problem. Not True!! The interplay of multiple factors is often at the root of sexual behavior problems, therefore: An assessment should be focused on the: Current factor that are maintaining the SBP Current factors that are restraining the SBP

Assessment: Scope : 

Assessment: Scope The Role of Formal Testing They can help estimate the extent and nature of the SBP The Child Sexual Behavior Inventory III (Friedrich) Is available at: www.parinc.com Child Sexual Behavior Checklist-2nd Revision (Johnson & Friend) Is available through Toni C. Johnson

Slide 28: 

Additional Assessment Issues to Consider: Adult and adolescent sexual behavior assessments are inappropriate for children It is imperative that assessment recommendations are used only in the present time. Children develop and mature over time and it’s not appropriate to refer to a childhood assessment that was done in the distant past Assessments should address the best interest and welfare of the child, including how interventions may negatively affect the child

Assessment tools in your folder : 

Assessment tools in your folder Tool from Friedrich Form B Safety Checklist Form C Family Sexuality Index Form D Therapist Rating Scale Form E Parent-Child Conflict Tactics Scale Tool from Johnson Family Roles, Relationships, Behaviors and Practices : A Questionnaire

Time for Lunch! See you back at 12:45 : 

Time for Lunch! See you back at 12:45

Treatment: What does the research tell us? : 

Treatment: What does the research tell us? Improvement in SBP when it is detected and adult intervention is provided Focused treatment helps, specifically structured SBP-approaches that include the parent or caregiver (as opposed to unstructured supportive therapy or play therapy without the parent or caregiver ) Blended CBT treatment targeting both SBP and traumatic stress symptoms is successful when both are present Good results can be obtained with a broad range of children with SBP using short-term outpatient CBT When there is active parent or caregiver involvement the outcomes are excellent.

Successful CBT Treatment Programs Common Components for Children : 

Successful CBT Treatment Programs Common Components for Children Identifying recognizing the inappropriateness of and apologizing for rule-violating sexual behaviors that occurred. Learning and practicing basic, simple rules about sexual behaviors and physical boundaries. Age appropriate sex education Coping and self-control strategies. Basic sexual abuse prevention/safety skills Social skills

Successful CBT Treatment Programs Common Components for Parents : 

Successful CBT Treatment Programs Common Components for Parents Developing and implementing a safety plan. This includes the following: A supervision and monitoring plan, especially monitoring interactions with other children. Communicating with other adults (such as day care personnel or extended family) about supervision needs. Modifying the safety plans over time.

Successful CBT Treatment Programs Common Components for Parents : 

Successful CBT Treatment Programs Common Components for Parents Information about sexual development, normal sexual play and exploration, and how these differ from SBP Strategies to encourage children to follow privacy and sexual behavior rules Factors that contribute to the development and maintenance of SBP and how to maintain an environment that is not overly sexually stimulating for the child Sex education and how to listen and talk with children about sexual matters

Successful CBT Treatment Programs Common Components for Parents : 

Successful CBT Treatment Programs Common Components for Parents Parenting strategies to build positive relationships with children and address behavior problems. Supporting children’s use the self control strategies they have learned Relationship building and appropriate physical affection with children Strategies to guide the child toward positive peer groups The emotional quality of the parent-child relationship also may be important to address with a focus on enhancing supportive, positive, and mutually enjoyable interactions.

Interventions Children : 

Interventions Children Identifying Problematic Sexual Behavior Form F 21 Questions Part 1: The place and the things in it Part 2: People’s Actions Part 3: Thoughts and Feelings Mapping Out My Touching Problem Teaching Boundaries and Rules about Sexual Behavior Form K Sexual Rules What is Sexually Intrusive Behavior Use of a Hoola Hoop The Development of a Behavior Plan (to be done with parent/caregiver) (Plan to Modify Problematic Sexual Behaviors)

Interventions Children : 

Interventions Children Feelings Identification Playing Detective Touching Times Feelings: When you have it, What you do about it Color Your Life Feelings: Inside and Outside Feelings Ball Catch Bibliotherapy Joy Berry Books: Let’s Talk About Feeling Sad, Angry, Ect.. Just Because I Am

Interventions Children : 

Interventions Children Coping Skills for Anxiety and/or Trauma Issues The Worry Wall Changing Your Self-Talk Bibliotherapy Brave Bart When Something Terrible Happens Cool Cats Calm Kids Trauma-Focused Cognitive Behavioral Therapy   http://tfcbt.musc.edu/  National Child Traumatic Stress Network http://www.nctsnet.org The National Institute for Trauma and Loss in Children http://www.starrtraining.org/tlc

Interventions Children : 

Interventions Children Affect Regulation/Self-Control Form M Turtle Technique Road Maps Radio Dial Metaphor Weekly Charts Bibliotherapy Self-Control Patrol Workbook How Does Your Engine Run Program A Volcano in My Tummy We Can Get Along

Break time ~ Be back at 2:30am : 

Break time ~ Be back at 2:30am

Interventions Parents or Caregivers : 

Interventions Parents or Caregivers Developing and Implementing a Safety Plan Form B Safety Checklist Review this Form with Parents/Caregivers and decide what things in the home must be modified Decreasing the Problematic Sexual Behavior Plan to Modify Problematic Sexual Behaviors Sex Education There are a variety of workbooks for children, Johnson has Sex Education materials in her books Behavior Management Skills Discipline Inventory Establishing a Routine Setting up House Rules

Interventions Parents or Caregivers : 

Interventions Parents or Caregivers Behavior Management Skills Discipline Inventory There are a variety of Parenting Skills Classes 1-2-3 Magic Love and Logic Relationship Building Skills Form O (PCIT) Healthy Parenting Handout Bibliotherapy Growing Up Again: Parenting Ourselves, Parenting Our Children Parenting from the Inside Out: How a deeper self- understanding can help you raise children who thrive Healthy Parenting: An Empowering Guide for Adult Children

Public Policy Considerations : 

Public Policy Considerations Do children with SBP pose a risk to other children and the community? Not much research yet in this area One 10 year follow-up study showed children with SBP were no more likely than children with nonsexual behavior problems Legal Response and Culpability ATSA advocates that children NOT be automatically adjudicated as delinquents for a sexual offense Children are naturally less culpable than adults Advocate for a case by case judgment Best interests of the child with SBP The long-term development and well-being of all children must be considered with a balance between the interests of the child and the community

Public Policy Considerations : 

Public Policy Considerations Labeling Professionals should be very mindful of NOT labeling children as sex offenders, predators, or perpetrators Instead label the behavior: children with sexual behavior problems Specific Public Policy Recommendations Registration and Public Notification Half of the states require adolescents and child who have been adjudicated for a sex offense to register as sex offenders This is highly stigmatizing and offers the community no protection as children are not a high-risk group Mandatory Child Abuse Reporting ATSA advocates that SBP between children NOT be reported UNLESS there is either: significant harm/exploitation or serious and persistent behaviors

Policies related to Placement : 

Policies related to Placement Placement Decisions ATSA believes children with SBP DO NOT require automatic out-of –home placement; even when the child has sexually victimized another child in the same home Removal should be considered when one of the following conditions is found: Source of serious distress or need for relief Reasonable less restrictive efforts have failed to curtail serious SBP Lack of reasonable effort combined with serious SBP Exceptional circumstances If out-of-home placement is needed, the least restrictive environment should be sought (foster care vs. residential)

Facts to remember about children with SBP : 

Facts to remember about children with SBP Childhood SBP range widely in their degree of severity and potential harm to other children; given fact, this treatment decisions should be made on a case by case basis Children with SBP appear to be at very low risk to commit future sex offenses Children with SBP appear to respond well and quickly to out patient treatment Children with SBP are qualitatively different from adult sex offenders Policies placing children on public sex offender registries offer little or no protection to the community and stigmatize children

Self-Care is Critical Parting Challenge:Care for yourself the way you Care for Others : 

Self-Care is Critical Parting Challenge:Care for yourself the way you Care for Others